Healthy Homes Checklist for Residential Properties (short version)

Healthy Homes Checklist for Residential Properties (short version)

Quick observational checklist for community healthcare workers using a traffic light system
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The owner of this form is Shareen Elnagy
Complete the checklist using both:
- What you observe when entering the property and checking each room
- What the resident tells you when asked or voluntarily discloses
Do not move furniture, inspect building elements or diagnose technical problems.

Tick any item that applies even if you are not 100% sure.

Add brief comments if helpful, including locations of damp, mould or other concerns.

If one or more concerns are identified, consider referral to Warm & Safe Wiltshire or your local support service. Obtain the resident's consent before making a referral.

Follow safeguarding procedures if there is an immediate risk to the residents’ health or safety.
Referrer's name

First NameLast Name
Referrer's job role
Referrer's email
Resident's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resident's name

First NameLast Name
Resident's phone number and/or email
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Today's weather (Helps to provide context on indoor conditions)
How would you describe the need? (See below for how to assess)
Urgent
• Significant mould in living or sleeping areas
• Home extremely cold or hot
• Major leak or flooding
• Resident unable to afford heating
• Broken or no heating
• Health condition potentially affected (e.g. respiratory disease)

Needs follow-up
• Condensation on windows
• Small patches of mould
• Draughty rooms
• Heating not working well
• Indoor clothes drying with poor ventilation

Monitor
• Home generally warm, dry and well ventilated
• No visible disrepair
• No reported concerns
Ask the client: "If you could change one thing about your home to improve your health or comfort, what would it be?"
Action Required?
If you ticked the escalation box above, please give details
If you ticked Refer to Warm & Safe Wiltshire, please tell us which service.

Other
If you selected 'Other' please give details
Add details to the option(s) you selected in the question above.
If you're referring a client, please tick the box below to confirm that permission has been granted by the client to share their details. For more information about how we use personal information please see CSE's privacy policy.
Should be Empty: